Original Investigation Selective fetal reduction in monochorionic twins: Preliminary experience Selective fetal reduction in monochorionic twins Vatsla Dadhwal, Aparna K. Sharma, Dipika Deka, Latika Chawla, Nutan Agarwal Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India Address for Correspondence: Vatsla Dadhwal e.mail: vatslad@hotmail.com DOI: 10.4274/jtgga.2018.0052 Received: 1 June, 2018 Accepted: 8 October, 2018 INTRODUCTION It is a well-accepted fact that multiple pregnancies have more maternal complications (abortion, preterm labor, preterm pre-labor rupture of membranes, hypertension in pregnancy, anemia, ante and post-partum hemorrhage, malpresentation, cesarean section) and fetal complications (malformations, intrauterine fetal growth restriction, and complications of prematurity) [1]. Therefore, with triplet and higher order gestation, fetal reduction to achieve a total number of two live fetuses is offered to couples with an aim of minimizing these complications. Fetal reduction from twin to singleton in dichorionic twins is debatable, but selective termination in twin gestation discordant for malformations or genetic abnormality is acceptable [2]. In monochorionic twins, fetal reduction may be performed for indications other than twins discordant for anomalies. Monochorionic twins have a unique set of complications such as twin-to-twin transfusion syndrome (TTTS), selective fetal growth restriction (sFGR), and twin reversed arterial perfusion sequence (TRAP). These complications are due to the presence of inter-fetal vascular anastomoses, which may put one twin at risk of death and adversely affect the health of the other twin. In the event of one twin dying, the transfer of a significant amount of blood from the normal to the dying fetus, through these placental vascular anastomoses, may occur leading to hypotension, hypo-perfusion of the brain leading to cerebral injury (20-30%) and fetal demise (up to 10%) [3-5]. In a situation where death in one twin is imminent but pregnancy is very preterm, resorting to fetal reduction can optimize outcomes in the surviving twin. Unlike dichorionic pregnancies, fetal reduction using potassium chloride (KCl) instillation in fetal thorax/heart is not an option in mono-chorionic twins due to the presence of placental vascular anastomosis; KCl might transfer to the other fetus and thus inadvertently cause demise of both twins. Vaso-occlusive techniques such as bipolar cord coagulation (BPCC), radiofrequency ablation (RFA), interstitial laser ablation (ILA) of cord, and fetoscopy-guided cord coagulation with laser are the methods proposed for selective fetal reduction in complicated monochorionic twins [6]. We describe our experience of selective fetal reduction in complicated monochorionic twin pregnancies at a Maternal Fetal Medicine unit in a tertiary care center in India. Methods This is a prospective study that included 31 patients with complicated mono-chorionic twin pregnancies who underwent selective fetal reduction from June 2013 to June 2017, in our unit. The pregnancies were very preterm and at risk of demise of one fetus, which could have adversely affected the other fetus. Informed written consent was obtained from each patient prior to the procedure. The analysis and publication of these data was approved by the institutional ethics committee. Methods used for cord coagulation were ILA, BPCC, and RFA. ILA was used for fetal reduction in the first half of the study period, whereas in the second half BPCC and RFA was used. The choice of method also depended on the period of gestation and the indication for reduction. Uncorrected Proof